Pure Pedantry

Much is made by politicians about the benefits of preventive medicine. Politicians often treat preventive medicine like it can perform fiscal magic, causing health care expenditure to evaporate.

The reality is that some preventive medicine is cost-effective and some of it is not. How effective pushing preventive medicine will be at reducing costs depends very heavily on which preventive medicine you choose to emphasize.

Such is the thrust of Cohen et al., publishing in the New England Journal of Medicine. Cohen et al. surveyed the literature on preventive medicine using a database from Tufts. They identified articles that assessed future costs and benefits for medical care intended to prevent or avert diseases — 599 in all.

Of the treatments surveyed many were found to be “cost-saving” meaning that they improved health and lowered costs. Some were found to both increase cost and worsen health. In between, there were a variety of treatments that have mixed cost-effectiveness. These are measured using a ratio of the cost in dollars to the quality-adjusted life-years (QALYs) — a measurement of the improvement in health that results from the treatment.

Below is a selection of what they found (Figure 2 in the paper). Click to enlarge.

i-6e5fd1622a546cc2ab482c7e4dbf8356-01t1small.jpg

You can see the cost-effectiveness for preventive measures and treatments is highly variable. Innoculation for H. flu (the Hib vaccine) is cost-saving, while screening all 65-year-olds is incredibly expensive considering the quality of life improvement obtained. Some preventive measures are even counter-productive such as some antibiotic prophylaxis.

The authors summarize their findings from a review of the literature:

Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer. In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient. In the case of screening, efficiency also depends on frequency (more frequent screening confers greater benefits but is less efficient). Third, as is the case for preventive measures, treatments can be relatively efficient or inefficient.

Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective). (Emphasis mine.)

Two things.

One, the realization that many diseases are preventable is only part of the process of lowering costs. For example, we could really limit health care costs in this country by lowering the number of smokers. The question is how to go about that most cheaply. Do you go with anti-smoking programs with children or quit-smoking programs in adults or tobacco taxes?

Second, I think that some people have an almost visceral rejection to applying cost-benefit analysis to health care. We would like to believe that health care — because it is desirable — should be unlimited and not subject to economic considerations. The sad fact is that health care is a limited commodity. It is the product of human labor, and as a consequence we have to make choices in allocating it.

Some of the preventive measures people advocate are not cost-effective. If you want to cut the cost of health care in this country, people are going to have to go without these measures — provided they are not willing to pay for themselves. And politicians do us no favors by hiding that reality.